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HX64066495 
RD81  L962  Anewgas-oxygen-etn 


RECAP 


NEW  GAS-OXYGEN-ETHER  AP- 
I  VI  ATJb  ;  DESCRIPTION  AND 
ijsl  of  rHE  INSTRUjVIENT. 

BY 

H.  CLIFTON  LUKE,  M.D. 

NEW  YORK. 

Anesthmist  to  St.  Luke's  Hospital. 


REPRINTED   FROM 
THE 

MEDICAL  RECORD 

June  12,  1915 


WILLIAM  WOOD  &  COMPANY 

NEW    YORK, 


Ml — 

CoUege  of  $f)pg;cian£(  anb  ^urgeonsJ 
Hibrarp 


Digitized  by  tine  Internet  Arciiive 

in  2010  witin  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/newgasoxygenetheOOIuke 


A    NEW    GAS-OXYGEN-ETHER    APPARATUS; 
-  DESCRIPTION  AND  USE  OF  THE 
INSTRUMENT. 

By  H.  CLIFTON  LUKE,  M.D.. 

NEW    YORK. 
ANESTHETIST  TO   ST.   LUKE'S    HOSPITAL. 

For  the  safe,  intelligent,  and  satisfactory  adminis- 
tration of  nitrous  oxide  in  general  surgery  an 
efficient  and  practical  apparatus  of  comparative 
simple  design  is  of  first  importance,  and  the  writer 
believes  that  the  following  requirements  should  be 
met  in  such  an  instrument: 

1."  Provision  for  the  even  and  continuous  delivery 
of  nitrous  oxide  and  oxygen  by  the  use  of  reducing 
valves. 

2.  An  unchangeable  and  sufficiently  accurate 
device  from  a  clinical  standpoint  for  separately 
measuring  these  gases. 

3.  Independent  valve  controls  for  each  gas. 

4.  A  system  of  rebreathing  and  ventilation  which 
without  waste  or  excessive  accumulation  of  carbon 
dioxide  will  insure  a  fairly  even  mixture  of  the 
gases  in  the  rebreathing  bag  at  all  times. 

5.  A  reliable  ether  device  which  has  independent 
valve  control, 

6.  Four  yokes  to  accommodate  two  gas  and  two 

Copyright,   William   Wood   &   Company. 
1 


oxygen  cylinders,  the  extra  one  of  each  serving  as 
a  reserve  supply. 

7.  The  instrument  should  be  obtainable  in  port- 
able form;  substantially  built  with  as  little  glass 
and  other  fragile  parts  as  possible.  With  these 
ideas  as  a  guide,  the  writer  has  planned  and  com- 
pleted the  apparatus  here  described. 

Description  of  Apparatus  (See  Fig.  1). — A 
graduated  ether  reservoir  of  about  one  ounce 
capacity  is  seen  above  and  in  the  center.  This  is 
controlled  by  a  pin  valve  (1)  which  allows  the  ether 
to  pass  drop  by  drop  through  the  sight  feed  (2), 
whence  it  falls  into  the  vaporizing  chamber  (3), 
through  which  a  stream  of  all  the  used  gases  are 
made  to  pass.  A  small  opening  closed  with  a  screw 
cap  (4)  is  used  for  filling  the  ether  cup,  while  a 
pet-cock  (5)  in  the  dependent  part  is  used  to  empty 
it.  At  the  lower  part  of  the  instrument  are  four 
yokes;  two  on  the  right  (6)  to  accommodate  two 
100-gal.  nitrous  oxide  cylinders,  and  two  on  the 
left  (6A)  for  two  40-gal.  oxygen  cylinders.  These 
yokes  are  strongly  connected  to  a  solid  brass  seg- 
ment (7),  which  is  tunneled  on  each  side  so  that 
the  gas  from  both  cylinders  may  pass  through  it 
and  upward  through  the  high-pressure  pipe  (8), 
the  oxygen  taking  a  similar  course  on  the  left, 
thence  entering  the  reducing  valve  (9),  the  oxygen 
passing  through  the  opposite  valve  (9A).  From 
these  valves  the  gases  pass  through  the  low-pressure 
tubing  (10,  lOA)  to  the  final  control  cocks.  A  low- 
pressure  gauge  of  30  pounds  capacity  is  attached 
on  each  side  (11,  11  A),  distal  to  the  regulators,  to 
indicate  the  pressure  against  these  control  cocks. 
The  circular  plates  (12,  12A)  are  immovably  at- 
tached to  the  stem  of  these  cocks.  A  calibration  ap- 
pears on  the  upper  part,  which  is  read  from  a  fixed 


indicator  point  (13)  in  the  center  at  the  top  of  each, 
in  terms  of  liters  per  minute  of  the  gas  delivered  to 
the  rebreathing  bag.    On  the  lower  side  of  this  cir- 


FlG.    1. 

cular  plate  is  a  gearing  which  engages  a  pinion 
whose  shaft  is  continuous  with  the  two  thumb- 
screw controls  (14  and  14A).    An  electrical  heating 

3 


attachment  (15)  is  built  into  the  nitrous  oxide  con- 
troller. This  line  is  also  tapped  to  provide  a  con- 
nection (17)  for  the  ether  heating  device.  The 
main  portion  of  the  apparatus,  consisting  of  the 
center  segment  (7)  supporting  the  yokes  and  all 
above  this,  is  one  connected  unit,  and  may  be  raised 
or  lowered  by  use  of  the  spring  catch  (20)  placed 
at  the  upper  part  of  the  supporting  stand.  If  it  is 
desired  to  use  only  one  tank  of  oxygen  and  one  of 
nitrous  oxide  on  the  machine,  the  tv^o  unused  yokes 
are  closed  off  by  inserting  into  the  same  the  tvv^o 
adjustable  dummies  or  blanks  (19).  The  one  on 
the  right,  not  numbered,  is  seen  in  position.  The 
portable  stand  (Fig.  2)  is  light,  strong,  and  can 
be  easily  taken  apart  and  packed  into  a  small  com- 
partment in  the  carrying  case.  The  rubber  outlet 
tubing   (18)   conducts  the  gases  to  the  face  mask. 

A  cut  of  the  apparatus  as  recently  made  up  for 
hospital  use  is  shown  in  Fig.  4.  A  number  of  minor 
improvements  have  been  made  on  this  new  model, 
but  it  chiefly  differs  from  the  original  portable  one 
by  having  a  strongly  constructed,  non-collapsible 
stand  which  can  be  raised  or  lowered  if  desired. 
A  larger  ether  reservoir  has  also  been  used  here, 
and  control  cocks  have  been  placed  on  each  yoke, 
thus  obviating  the  little  inconvenience  of  moment- 
arily turning  off  the  supply  of  gas  or  oxygen  to 
the  rebreathing  bag  while  a  full  tank  is  being  in- 
serted on  either  side  in  place  of  an  empty  one. 

Calibration  of  the  Instrument. — The  volume  of  a 
gas  delivered  at  a 'fixed  and  standard  pressure  (ten 
pounds  in  this  case)  through  a  graduated  metal 
cock  is  very  constant,  and  should  remain  so  under 
such  conditions  for  an  indefinite  period.  In  this 
apparatus  a  large  cock  has  been  constructed  of  hard 
composition-metal  with  an  extra  long  tapered  stem. 


accurately  ground  and  fitted,  having  an  offset  to 
prevent  leakage  in  the  arrangement  of  the  inlet 
and  outlet  channels.  A  pair  of  small,  tapering  V- 
shaped  grooves  in  the  stem  in  connection  with  the 
channels  regulates  the  escape  of  the  gases.  For 
purposes  of  calibration  a  circular  metal  plate  was 
attached  immovably  to  the  stem  of  the  cock  and  a 
fixed  indicator  point  arranged  at  the  top  of  this 
plate.  A  reliable  and  proved  dry  gas  meter  of  the 
three-light  type  was  attached  distally  to  the  valve 
which  was  furnished  with  a  gas  supply  at  an  even 
pressure  of  ten  pounds.  The  cock  was  then  opened  to 
a  point,  for  instance,  where  the  gas  meter  indicated 
that  the  delivery  rate  was  2  liters  per  minute,  then 
to  a  point  where  4  liters  per  minute  was  delivered, 
and  so  on  until  on  the  nitrous  oxide  side  a  calibra- 
tion was  made  for  2,  4,  6,  8,  10  and  12  liters  per 
minute,  while  on  the  oxygen  side  the  reading  in 
liters  was  i/^,  1,  II/2,  2,  2y2  and  3  per  minute. 
Finer  changes  could  be  had  by  opening  the  valve  to 
points  between  those  placed  on  the  scale.  A  man- 
ometer was  attached  distally  to  the  meter  and  a  re- 
sistance from  3  to  5  mm.  of  mercury  was  carried 
during  the  calibration,  which  would  compensate  for 
the  slight  positive  pressure  usually  present  in  the 
breathing  bag  and  mask.  Horvever,  the  effect  on 
the  amount  of  gases  delivered  is  so  slight  that  this 
is  unnecessary. 

Necessity  of  a  Heating  Device. — In  a  portable 
apparatus  of  this  kind  the  small  cylinders  containing 
40  gallons  of  oxygen  and  100  gallons  of  nitrous 
oxide  are  mostly  used.  In  the  case  of  oxygen,  where 
the  tank  pressure  is  about  1,200  to  1,500  pounds,  it 
can  be  reduced  and  maintained  at  an  even  pressure 
of  10  pounds  without  difficulty,  since  it  is  used 
so  slowly  that  a  relatively  small  amount  of  cold  is 


generated  (average  1  liter  or  less  per  minute)  ;  but 
with  nitrous   oxide  the  rate  is  4  to   6  liters   per 


Fig.  2.— Portable  apparatus;  weight  22  lbs.  without  cylinders. 

minute,  and  the  ordinary  controllers  tend  to  alter- 

6 


nately  freeze  and  thaw  after  the  first  fifteen  and 
twenty  minutes,  causing  a  continuous  fluctuation 
of  the  low  pressure.  This  must  be  overcome,  since 
the  accuracy  of  any  measuring  device  for  gases  is 
dependent  quite  as  much  on  the  constancy  of  the 
pressure  as  on  the  amount  of  it.  By  the  use  here  of 
a  regulator  having  incorporated  in  its  body  a  good 
electric  heater  it  has  been  found  possible  to  secure 
and  maintain  a  10-pound  pressure  continuously^  for 
long  periods. 

The  Ether  Device. — When  ether  is  needed,  it  is, 
by  the  use  of  a  direct  thumb  control  at  the  top  of 
the  ether  chamber,  caused  to  be  sent  through  the 
sight  feed  drop  by  drop  into  the  electrically  heated 
tunnel,  through  which  all  the  gases  are  made  to 
pass  in  a  sweeping  uphill  direction,  the  ether  tend- 
ing to  run  downward  against  the  oncoming  stream 
of  gases.  This  mechanical  arrangement  assists  sub- 
stantially in  the  vaporizing  of  the  ether.  The  tun- 
nel has,  in  general,  the  course  which  the  letter  U 
would  indicate  when  the  latter  is  placed  on  its  side, 
thus  U  ;  the  space  between  the  two  limbs  of  the 
letter  representing  a  receptacle  for  a  tubular  elec- 
tric light  which  affords  ample  heat  to  prevent  any 
freezing  tendency  of  the  ether  even  when  being 
vaporized  at  the  rate  of  60  to  120  or  more  drops 
per  minute.  This  heater  can  be  disconnected  inde- 
pendently, and  need  only  be  used  when  rather  large 
amounts  of  ether  are  called  for. 

The  Face  Mask  and  Other  Parts. — In  an  effort  to 
simplify  the  portable  apparatus  and  lessen  its 
weight,  turn-off  valves  have  not  been  provided  in 
connection  with^the  yokes,  but  instead  two  light 
adjustable  dummies  or  blanks,  one  on  each  side,  are 
available  to  lock  in  the  unused  yokes  in  case  only 
one  tank  is  inserted  on  each  side.     The  conducting 


tube  from  the  instrument  to  the  rebreathing  bag 
should  have  about  one-quarter  inch  inside  diameter. 


Fig.   4. — Hospital  apparatus. 
8 


and  be  relatively  short,  that  is,  about  4  feet.  The 
reasons  for  this  are,  first,  to  avoid  possible  accumu- 
lation of  expired  gases  in  the  tube,  and,  second- 
ly, to  allow  the  quick  delivery  of  fresh  gases  into 
the  rebreathing  bag.  The  rebreathing  bag  is  placed 
next  to  the  face  piece,  thus  facilitating  the  ease  of 
respiratory  interchange  which  would  not  be  obtained 
were  a  long,  rigid  tube  to  intervene  between  the 
mask  and  working  supply. 

The  Boothby-Cotton  rubber  face  piece,  an  im- 
provement on  the  one  originally  devised  by  Gatch, 
has  been  modified  here  by  providing  extensions  at 
the  chin  and  nasal  ends,  and  attaching  the  retaining 
straps  at  a  more  acute  angle  with  a  double  adjust- 
able loop  to  fit  over  the  crown  of  the  head,  thus 
leaving  the  back  of  the  neck,  so  often  the  site  of 
abscesses  and  carbuncles,  free  as  a  field  for  opera- 
tion. A  celluloid  hood  is  used,  and  the  metal  parts 
of  the  mask  are  of  light  weight  so  that  the  rubber 
face  piece,  with  its  adjustable  strap,  makes  the 
mask  practically  self-retaining.  The  exhalation 
valve  has  been  specially  designed,  and  regulates  the 
ventilation  very  evenly.  It  consists  of  a  valve  seat, 
above  which  is  a  flat,  circular  aluminum,  float,  which 
rides  freely  up  and  down  on  a  small  triangular- 
shaped  vertical  standard  running  through  its  center. 
The  float  is  kept  seated  by  a  very  delicate  adjustable 
coil  spring.  The  valve  is  all  metal,  and  can  be 
easily  taken  apart  and  boiled.  The  rubber  face 
piece  can  be  briefly  boiled  many  times  without 
serious  damage;  but  the  celluloid  hood*  should  be 
sterilized  in  bichloride  or  oxycyanide  of  mercury 
solutions. 

General  Technique  and  Use  of  the  Instrument. — 
In  advance  of  the  actual  administration  it  is  very 

*An  aluminum  hood  will  be  tried  in  the  near  future. 


important  to  give  some  alkaloidal  adjuvant,  since 
gas-oxygen  as  compared  with  ether  or  chloroform 
is  just  a  veneer  form  of  anesthesia.  In  the  average 
case  we  have  found  that  morphine  sulphate,  1/6 
grain  with  hyoscine  hydrobromate,  1/200  grain, 
given  together,  hypodermically,  one  hour  before 
operation  is  very  safe  and  satisfactory.  Where  a 
definite  contraindication  to  the  use  of  hyoscine 
exists,  atropine  sulphate,  1/100  grain  may  be  sub- 
stituted. In  the  old  and  the  young  we  usually  omit 
the  preliminary  medication.  The  morphine,  aside 
from  its  general  sedative  effect,  is  an  efficient  aid 
in  blocking  shock,  while  hyoscine  gives  substantial 
help  through  its  powerful  cerebral  sedative  action. 
It  should  also  be  remembered  that  at  the  start  a 
word  of  explanation  and  encouragement  to  the 
patient  but  seldom  fails  to  do  real  good,  and  fre- 
quently helps  materially  to  accomplish  a  quiet, 
smooth  induction. 

The  ether  reservoir  should  always  be  filled,  and 
the  cock  on  the  pipe  running  downward  at  the  rear 
opened.  This  pipe  serves  to  equalize  the  air  pres- 
sure in  the  reservoir  and  vaporizing  chamber,  thus 
allowing  the  ether  to  escape  freely  from  the  former. 
One  should  also  be  certain  beforehand  that  an  ample 
supply  of  gas  and  oxygen  is  on  hand.  Our  ex- 
perience with  this  particular  instrument  indicates 
that  in  the  average  case  a  40-gallon  tank  of  oxygen 
will  suffice  for  about  two  hours  (average  rate  of  1 
liter  per  minute),  and  a  100-gallon  tank  of  nitrous 
oxide  is  usually  sufficient  for  about  1  hour  and  10 
minutes  (equal  to  4.84  liters  or  1.28  gallons  per 
minute) .  Amounts  of  oxygen  in  excess  of  the  aver- 
age, up  to  2  liters  per  minute,  are  occasionally  re- 
quired, because,  as  Connell  has  mentioned,  a  dimin- 
ished tidal  volume,   a  decreased   oxygen  carrying 

10 


capacity  of  the  blood  or  rate  of  blood  flow  must  be 
compensated  for  by  increased  oxygen  supply.  Prac- 
tical examples  of  this  are  seen  in  the  case  of  young 
children,  old  people,  individuals  with  marked 
anemia,  septic  cases,  those  with  diminished  pul- 
monary capacity,  as  in  advanced  tuberculous  condi- 
tions, pneumonia,  empyema,  etc.,  uncompensating 
cardiac  cases,  and  conditions  of  inanition,  exhaus- 
tion, and  shock  from  various  causes. 

Where  excessive  amounts  of  oxygen  are  demanded 
in  cases  not  exhibiting  such  deficiencies  it  is  usually 


H  1- 


J  D  E  A  B 


Fig.  3. — The  face  mask.  The  body  (A)  is  of  light  weight 
and  can  be  rotated  in  any  desired  direction.  The  thumb 
control  (B)  when  pushed  to  the  right  to  limit  of  slot  opens 
an  air  vent  on  the  opposite  side  of  the  body  ;  in  its  present 
position  the  air  vent  is  closed  and  free  interchange  of  gas 
is  allovv^ed  between  the  rebreathing  bag  (C)  and  mask.  The 
exhalation  valve  (D)  has  a  thumb  screw  (E)  to  regulate 
the  tension  of  its  spring.  The  nasal  end  (F)  of  the  rubber 
laood  shows  the  rubber  flap  beneath  which  cotton  is  packed 
on  each  side,  while  G  indicates  the  chin  extension.  H  is  the 
head  strap  and  J  the  celluloid  face  piece. 


due  to  partially  obstructed  breathing.  A  free  air- 
way, indicated  by  a  quiet,  regular  respiratory 
rhythm,  is  of  paramount  importance.  To  obtain 
this  some  mechanical  aid  is  frequently  necessary, 
and  we  have  found  that  the  simplest,  least  expensive 

11 


and  most  practical  device  consists  of  a  pair  of  fairly 
soft  rubber  tubes  of  about  %  inch  bore,  the  ends 
to  be  passed  into  the  mouth  over  the  base  of  the 
tongue  being  beveled  and  seared  in  a  flame  to  make 
them  smooth,  while  the  opposite  ends  which  pro- 
trude beyond  the  lips  are  pierced  by  a  strong  safety 
pin,  which  is  locked  and  has  attached  to  it  a  loop 
of  tape  6  inches  long,  which  will  extend  from  be- 
neath the  mask  to  the  outside.  They  are  simple  to 
make,  can  be  used  several  times,  and  are  readily 
sterilized  by  boiling.  If  sterterous  breathing  with 
cyanosis  persists  one  should  expose  the  mouth  by 
raising  just  the  lower  end  of  the  face  piece,  and 
with  firm  downward  pressure  of  the  chin  by  the  left 
hand,  if  necessary  to  overcome  the  set  jaw,  quickly 
pass  with  the  other  hand  the  tubes,  previously 
smeared  with  a  little  K-Y  lubricant,  between  the 
teeth  and  over  the  tongue  until  the  pinned  ends  ex- 
tend just  beyond  the  lips.  By  this  device  a  trouble- 
some and  often  dangerous  anesthesia  is  quickly  con- 
verted into  one  which  is  smooth-going  and  satis- 
factory, and  it  should  always  take  the  place  of  con- 
stant jaw  pressure,  which  is  irksome,  inefficient  and 
harmful.  During  the  past  four  years  this  device 
has  been  used  in  about  five  thousand  cases  of  gen- 
eral anesthesia  at  St.  Luke's  Hospital  with  the 
utmost  satisfaction. 

Before  adjusting  the  mask  the  air  vent  on  the 
body  of  same  should  be  closed ;  this  locks  in  the  bag 
any  gas  turned  into  it.  One  should  next  fill  the 
bag  about  three-fourths  full  of  pure  gas,  avoiding 
delay  by  opening  the  gas  valve  to  the  limit.  This 
done,  the  gas  is  turned  off  completely  until  the 
rubber  face  piece,  a  modification  of  the  Boothby 
hood,  is  arranged.  It  has  at  one  end  an  extension 
which  hooks  over  the  chin  and  lifts  it  somewhat, 

12 


thus  encouraging  the  forward  position  of  the  lower 
jaw  when  the  retaining  strap  which  goes  over  the 
crown  of  the  head  is  pulled  fairly  tight  and 
fastened.  The  nasal  end  fits  snugly  over  the  bridge 
of  the  nose,  but  does  not  bind.  Beneath  the  rubber 
flap  on  each  side  of  the  nose  should  be  tucked  a 
moderate-sized  wad  of  non-absorbent  cotton.  This 
gives  a  snug  fit  along  the  side  of  the  nose.  The  air 
vent  is  now  closed,  allowing  free  flow  of  gases  into 
the  face  mask  while  the  gas  valve  is  opened  to  the 
point  indicating  6  liters  per  minute,  and  the  oxygen 
valve  set  at  the  y2-liter  mark.  When  the  slightest 
bluish  tinge  appears  in  the  ear  (the  most  practical 
place  to  observe  color)  the  oxygen  is  turned  up  to 
the  1-liter  mark.  Later,  consistent  with  the  be- 
havior of  the  patient,  it  may  be  and  often  is  pos- 
sible to  decrease  the  gas  delivery  to  4  liters  per 
minute,  while  the  oxygen  indicator  may  usually  be 
held  at  or  a  little  behind  the  1-liter  mark.  Ho;vever, 
in  intractable  patients,  such  as  alcoholics,  large 
muscular  men,  highly  nervous  individuals,  etc.,  as 
miich  as  8  liters  of  gas  per  minute  may  be  required 
throughout.  This  is  also  the  case  where  the  tidal 
volume  is  much  increased,  due  to  very  rapid  and 
deep  breathing.  With  the  gases  delivered  at  the 
average  rate,  as  mentioned  above,  the  tension  of 
the  spring  in  the  exhalation  valve  should  be  so 
adjusted  that  the  rebreathing  bag  at  the  end  of  ex- 
piration is  completely  filled  without  being  tense. 
Positive  pressure  is  unnecessary  and  is  advised 
against. 

It  should  be  remembered  that  it  requires  from 
seven  to  ten  minutes  to  establish  a  good  gas-oxygen 
anesthesia,  which  does  not  mean  the  mere  state  of 
unconsciousness  usually  obtained  in  from  fifteen  to 
forty  seconds,  but  a  oalance  of  gases  between  the 

13 


alveolar  air  and  blood  which  will  maintain  a  suf- 
ficient saturation  of  the  nerve  centers  to  obtain  the 
most  complete  anesthetic  state  without  the  presence 
of  anything  more  than  a  very  slight  degree  of 
cyanosis. 

Ether  as  an  Adjuvant  to  Nitrous  Oxide. — It  is 
during  the  induction  period  when  a  relatively  light 
anesthetic  state  exists  that  the  moving  and  placing 
of  the  patient  in  special  positions,  followed  by  the 
powerful  reflex  stimulation  of  the  skin  incision 
(where  no  local  anesthetic  is  used),  and  this  in 
turn  perhaps  by  intraabdominal  manipulations, 
that  offers  some  of  the  greatest  difficulties  to  over- 
come with  this  anesthetic.  Ether  is  a  powerful 
synergist  to  nitrous  oxide,  and  it  is  due  to  this  fact 
that  a  pronounced  quieting  effect  is  frequently 
observed  during  the  induction  period  when  very 
small  amounts  (2  or  3  drachms)  are  added  at  the 
rate  of  40  to  60  drops  per  minute  over  a  period  of 
three  or  four  minutes.  After  this  in  a  majority 
of  cases  no  more  ether  will  be  required,  but  a  cer- 
tain percentage  of  these  will  necessitate  a  small 
amount  again  at  the  time  of  closing  the  wound, 
especially  when  it  is  in  the  upper  section  of  the 
abdomen. 

In  certain  intractable  cases  it  may  be  necessary 
to  continuously  add  a  little  ether  (20  or  40  drops 
per  minute)  throughout  the  operation,  and  at  the 
same  time  it  is  usually  best,  though  not  absolutely 
necessary,  to  increase  the  oxygen  percentage  suf- 
ficiently to  obtain  a  pronounced  pinkish  color.  The 
use  of  local  anesthesia  in  the  line  of  incision,  if 
surgeons  could  be  induced  to  use  it  routinely,  would 
conduce  to  a  much  more  quiet  anesthesia,  far  better 
muscular  relaxation  and  minimize  the  necessity  for 
the  use  of  ether  as  an  adjuvant. 

14 


At  the  commencement  of  this  article  certain  re- 
quirements were  set  forth  as  representing  the 
writer's  idea  of  a  clinically  efficient  and  practical 
gas-oxygen  apparatus.  It  is  believed  that  all  of 
these  have  been  attained  in  the  instrument  here 
described,  -and  the  final  test,  its  practical  utility, 
has  been  satisfactorily  established  during  the  past 
three  months  in  St.  Luke's  and  other  hospitals  here. 

204  West  110th  Street. 


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